Safe'N'Clear Order Form - Patricia Dobbs
This form is for orders placed through Patricia Dobbs only. Customers will be contacted separately to confirm their order. Customers will also be invoiced separately.

Customer payment terms initially will be 2% Discount If Paid In Advance / Net 30.

DO NOT provide payment information on this form. The customer will receive a separate invoice via email as the order is processed.
Customer & Company Name *
Your answer
Customer Email Address *
Your answer
Ship-To 1 *
Your answer
Ship-To 2
Your answer
Ship-To City, State, Zip *
Your answer
Customer Bill-To 1
Enter Bill To Address Information Only If Different From Ship To
Your answer
Customer Bill-To 2
Enter Bill To Address Information Only If Different From Ship To
Your answer
Customer Bill-To City, State, Zip
Enter Bill To Address Information Only If Different From Ship To
Your answer
Customer Contact Phone Number *
Your answer
PO Number (Or Other Information)
Your answer
The Communicator™ Case (10 Dispenser Boxes = 400 Masks) - $360.00 Each
The Communicator™ Dispenser Box (40 Masks) - $40.00 Each
Will Pay Prior To Shipment (Credit Card Via PayPal)
Other Comments / Information / Instructions
Your answer
http://infoquestsurveycompany.com
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